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HMO can make supplemental insurance unnecessary

(ran HT, PT, NP, TP, SP editions)

Question: My husband and I are paying a considerable amount each month for our Medicare supplemental insurance premium. We understand that Medicare supplemental insurance is unnecessary if we elect coverage under a Medicare HMO plan. What is a Medicare HMO and will we not need a Medicare supplemental insurance policy if we enroll in a Medicare HMO?

Answer: A Medicare health maintenance organization has a contract with the Health Care Finance Administration to provide subscribers within its service area all Medicare-covered services through the HMO's health care providers. The Medicare HMO must also provide or pay for emergency services rendered when subscribers are temporarily outside the service area.

Because most Medicare HMO plans also cover the Medicare deductibles and reduce the co-insurance to minimal levels, a Medicare supplemental insurance policy usually becomes unnecessary. It is important to remember that a Medicare beneficiary enrolled with an HMO must continue to pay the premium for Medicare Part B coverage.

While a Medicare HMO policy should be read closely to determine the extent of additional medical services, many Medicare HMOs also provide its subscribers coverage for benefits not provided by Medicare, such as prescription drugs, eye exams and lenses, hearing tests and preventive care. These additional benefits are normally provided subject to a small co-payment by the subscriber. Another advantage is that most Medicare HMO subscribers are covered for a stay in a skilled nursing facility without the three-day prior hospitalization required for Medicare Part A coverage.

Question: Are there any disadvantages to enrolling in a Medicare HMO?

Answer: The most evident disadvantage is that a Medicare beneficiary who selects a Medicare HMO is generally required to obtain the covered services only from physicians and hospitals designated by the HMO. This means that a subscriber to a Medicare HMO may not select any physician or hospital for medical services.

The physician selected by the subscriber from the HMO panel of physicians for basic care becomes not only the subscriber's primary care physician but also the gatekeeper to the subscriber's medical specialists. A Medicare HMO subscriber who desires treatment by a specialist or a second opinion from another specialist must first secure permission from his or her primary care physician. It is important to understand that the Medicare HMO also retains the right to review and override the primary care physician's recommendations or the patient's request for treatment. This form of gatekeeping and review is designed to maximize the efficient delivery of health care services and to prevent overtreatment.

While a subscriber has the right to file a grievance with regard to the Medicare HMO's denial of medical services, the subscriber may be forced to accept the possible undertreatment because the grievance process is lengthy.

If the Medicare HMO decides the medical service should not be allowed, the beneficiary must first submit a completed grievance form to the Medicare HMO's office. The Medicare HMO normally has 24 days in which to issue its decision. If the grievance is not favorably resolved by the HMO, the subscriber must then file a request for reconsideration with the HMO or the local Social Security office within 60 days of the HMO's determination.

The subscriber denied the requested medical service may ultimately appeal an adverse decision to an administrative law judge and then to the Appeals Council of Social Security. If the subscriber first exhausts all of these administrative remedies and the amount in controversy is $1,000 or more, the subscriber can request judicial review in federal court.

Question: Would my husband and I be eligible to enroll in a Medicare HMO since we are presently enrolled in Medicare Parts A and B?

Answer: Almost all Medicare beneficiaries who reside in the HMO's service area may enroll in the Medicare HMO. Federal regulations require that each qualified Medicare HMO have at least one annual 30-day open enrollment period. Only Medicare beneficiaries who have been medically determined to have end-stage renal disease or are terminally ill and have already made the hospice care election are ineligible to enroll in a Medicare HMO. While a Medicare beneficiary who enrolls in an HMO and later becomes terminally ill may choose to disenroll from the HMO and select the Medicare hospice election, the Medicare HMO may not require that a terminally ill beneficiary disenroll. Likewise, a Medicare beneficiary who enrolls in a Medicare HMO and later is medically determined to have end-stage renal disease may not be required to disenroll.

Question: If my husband and I enroll in a Medicare HMO, can we subsequently disenroll from a Medicare HMO?

Answer: A Medicare beneficiary who no longer desires to subscribe to the Medicare HMO may disenroll at any time by giving the Medicare HMO a signed request in the form and manner prescribed by the Medicare HMO. A Medicare beneficiary may also disenroll from a Medicare HMO at a local Social Security office. While a beneficiary may request a certain disenrollment date, it can be no earlier than the first day of the first month after the date in which the disenrollment request was made. It is also important that a person who disenrolls from a Medicare HMO renew his or her Medicare supplemental insurance and confirm that any waiting period for pre-existing conditions has elapsed.

It is important that a notify the Medicare HMO of a move or intended absence. Failure to notify the HMO of a permanent move or extended absence may result in payment for medical services outside the service area being denied.

_ Gregory G. Gay is a lawyer in Pasco County who specializes in elder law. You can write to him c/o Seniority, the Times, P.O. Box 1121, St. Petersburg, FL 33731.